02-031-850 Me. Code R. § 9

Current through 2024-46, November 13, 2024

Section 031-850-9 - Adverse Benefit Determinations not Involving Adverse Health Care Treatment Decisions

A .Notice of Adverse Benefit Determinations not Involving Health Care Treatment Decisions

Adverse benefit determinations involving medical issues (adverse health care treatment decisions) are subject to the written notice requirements of paragraph 8(E)(5). For any adverse benefit determination that does not involve medical issues, the carrier shall provide written notice that includes the information required below:

1) the principal reason or reasons for the determination;

2) reference to the specific plan provisions on which the determination is based;

3) information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount if applicable), and a statement that the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, will be provided upon request;

4) a description of any additional material or information necessary for the covered person to perfect the claim and an explanation as to why such material or information is necessary;

5) the instructions and time limits for initiating an appeal or reconsideration of the determination;

6) notice of the right to file a complaint with the Bureau of Insurance after exhausting any appeals under a carrier's internal review process. In addition, an explanation of benefits (EOB) must comply with the requirements of 24-AM.R.S.A. §4303(13) and any rules adopted pursuant thereto.

7) if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement referring to the rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse determination and explaining that a copy will be provided free of charge to the covered person upon request;

8) a phone number the covered person may call for information on and assistance with initiating an appeal or reconsideration or requesting review criteria;

9) a description of the expedited review process applicable to claims involving exigent circumstances;

10) the availability of any applicable office of health insurance consumer assistance or ombudsman established under the federal Affordable Care Act; and 11) any other information required pursuant to the federal Affordable Care Act.

B.First Level Review of Adverse Benefit Determinations not Involving Health Care Treatment Decisions

1) A grievance concerning any matter may be submitted by a covered person or a covered person's representative. Appeals of adverse health care treatment decisions are subject to the requirements of subsections 8(G) and 8 (G-1) of this rule. Review of other grievances is subject to this subsection and subsection C of this section.

2) A covered person does not have the right to attend, or to have a representative in attendance, at the first level grievance review, but is entitled to submit written material to the reviewer. The health carrier shall provide the covered person the name, address and telephone number of a person designated to coordinate the grievance review on behalf of the health carrier. The health carrier shall make these rights known to the covered person within 3 working days after receiving a grievance.

a) A health carrier shall issue a written decision to the covered person within 30 days after receiving a grievance. Additional time is permitted where the carrier can establish the 30-day time frame cannot reasonably be met due to the carrier's inability to obtain necessary information from a person or entity not affiliated with or under contract with the carrier. The carrier shall provide written notice of the delay to the covered person. The notice shall explain the reasons for the delay. In such instances, decisions must be issued within 30 days after the carrier's receipt of all necessary information. The person or persons reviewing the grievance shall not be the same person or persons who made the initial determination denying a claim or handling the matter that is the subject of the grievance.

b) If the decision is adverse to the covered person, the written decision shall contain:

i) The names, titles and qualifying credentials of the person or persons participating in the first level grievance review process (the reviewers).

ii) A statement of the reviewers' understanding of the covered person's grievance and all pertinent facts.

iii) Reference to the specific plan provisions on which the benefit determination is based.

iv) The reviewers' decision in clear terms, including the specific reason or reasons for the adverse benefit determination.

v) A reference to the evidence or documentation used as the basis for the decision. The decision shall include instructions for requesting copies, free of charge, of all documents, records and other information relevant to the claim, including any referenced evidence or documentation not previously provided to the covered person.

vi) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement referring to the rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse determination and explaining that a copy will be provided free of charge to the covered person upon request.

vii) A description of the process to obtain a second level grievance review of a decision, the procedures and time frames governing a second level grievance review, and the rights specified in subparagraph C(3)(c). Notice to the enrollee describing any subsequent external review rights, if required by 24-A M.R.S.A. §4312(3).

viii) Notice of the availability of any applicable office of health insurance consumer assistance or ombudsman established under the federal Affordable Care Act.

ix) Notice of the covered person's right to contact the Superintendent's office. The notice shall contain the toll free telephone number, website address, and mailing address of the Bureau of Insurance.

x) Any other information required pursuant to the federal Affordable Care Act.

C.Second Level Review of Adverse Benefit Determinations not Involving Health Care Treatment Decisions

1) A health carrier shall provide a second level grievance review process to covered persons who are dissatisfied with a first level grievance review determination under subsection B. The covered person has the right to appear in person before authorized representatives of the health carrier, and shall be provided adequate notice of that option by the carrier.

2) The carrier shall appoint a second level grievance review panel for each grievance subject to review under this subsection. A majority of the panel shall consist of employees or representatives of the health carrier who were not previously involved in the grievance.

3) Whenever a covered person has requested the opportunity to appear in person before authorized representatives of the health carrier, a health carrier's procedures for conducting a second level panel review shall include the following:

a) The review panel shall schedule and hold a review meeting within 45 days after receiving a request from a covered person for a second level review. The review meeting shall be held during regular business hours at a location reasonably accessible to the covered person. The health carrier shall offer the covered person the opportunity to communicate with the review panel, at the health carrier's expense, by conference call, video conferencing, or other appropriate technology. The covered person shall be notified in writing at least 15 days in advance of the review date. The health carrier shall not unreasonably deny a request for postponement of the review made by a covered person.

b) Upon the request of a covered person, a health carrier shall provide to the covered person, free of charge, all relevant information that is not confidential and privileged from disclosure to the covered person.

c) A covered person has the right to:

i) Attend the second level review;

ii) Present his or her case to the review panel;

iii) Submit supporting material both before and at the review meeting;

iv) Ask questions of any representative of the health carrier; and

v) Be assisted or represented by a person of his or her choice.

d) If the health carrier will have an attorney present to argue its case against the covered person, the carrier shall so notify the covered person at least 15 days in advance of the review, and shall advise the covered person of his or her right to obtain legal representation.

e) The covered person's right to a fair review shall not be made conditional on the covered person's appearance at the review.

f) The review panel shall issue a written decision to the covered person within 5 working days after completing the review meeting. A decision adverse to the covered person shall include the information specified in subparagraph B(2)(b).

02-031 C.M.R. ch. 850, § 9